Beyond the Liver: Uncovering an Atypical Presentation of Metastatic Hepatocellular Carcinoma

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Abstract Introduction Hepatocellular carcinoma (HCC) frequently metastasizes to the lungs. The most common presenting symptom is gradual decline in respiratory function. Acute respiratory failure as an initial presentation of metastatic HCC is uncommon. Case presentation An 84-year-old female presented with a three-day history of cough and blood-streaked sputum, worsening liver function, acute kidney injury (AKI), and leukocytosis. She was treated with antibiotics for suspected pneumonia and a bicarbonate drip for AKI. A chest CT showed bilateral ground-glass opacities and nodules, indicating possible atypical pneumonia. Her respiratory status deteriorated, leading to ICU transfer, intubation, and mechanical ventilation. Bronchoscopy with transbronchial biopsy confirmed metastatic spread from undiagnosed hepatocellular carcinoma (See figure 1). After stabilizing with supportive care, she was extubated. Given the advanced cancer and poor prognosis, further cancer workup was ceased, and she was transitioned to palliative care and discharged. Discussion Metastatic disease should be considered when diagnosing acute respiratory symptoms, especially in older patients without a known history of malignancy. Lung metastases occur in 20% to 50% of HCC cases and are often detected through routine imaging or follow-up. Median survival after diagnosing pulmonary metastasis ranges from 6 to 11 months, depending on the extent of the disease and liver function.Accurate diagnosis of lung metastases is critical for managing HCC effectively. Bronchoscopy, especially when using transbronchial lung biopsy (TBLB) and endobronchial ultrasound (EBUS), provides a minimally invasive and highly effective method for diagnosing lung metastases from HCC. These techniques are particularly useful for detecting lesions located in peripheral lung regions or those invading the bronchial lumen, where direct sampling is possible. Combining bronchoscopy with advanced liquid biopsy techniques, such as detecting circulating tumor cells (CTCs) or cell-free DNA (cfDNA) from bronchoalveolar lavage (BAL) fluid, further enhances diagnostic accuracy. This comprehensive approach allows for the detection of metastatic cells that may not be visible on imaging, providing a more complete assessment of disease spread.Identifying lung metastases early enables clinicians to tailor treatment strategies more precisely, potentially incorporating targeted therapies or immunotherapy. These advanced treatments can improve survival outcomes for patients with advanced HCC, emphasizing the importance of thorough and accurate diagnostic processes in managing this disease. Early detection and appropriate intervention are key to improving patient prognosis and quality of life.

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